Current issues of ACP Journal Club are published in Annals of Internal Medicine


Letter

Review: Vaginal signs and symptoms perform poorly in diagnosing vaginal candidiasis

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ACP J Club. 2005 Mar-Apr;142:A13. doi:10.7326/ACPJC-2005-142-2-A13



To the Editor

I read with interest the commentary by Doust in the Sep/Oct issue (1). I concur that the laboratory evaluation of vaginitis, in general, is superior to individual historical and physical findings. However, 3 additional points deserve emphasis. First, evaluating combinations of clinical findings for calculating likelihood ratios (LRs) would be helpful, as combinations have been evaluated in at least 1 other clinical entity (2). Second, evaluating LRs for previous use of antibiotics may prove useful, since they can predispose to vaginal candidiasis). Third, I would like to emphasize the value of the lack of odor in bacterial vaginosis (BV) and lack of yellow discharge in vaginal trichomoniasis (VT), as the negative LRs are 0.07 and 0.12, respectively. A physician could make the decision to treat a woman empirically for vaginal candidiasis with over-the-counter intravaginal miconazole without performing an expensive laboratory examination, provided there was no history of odorous discharge (BV) or yellow discharge (VT). For example, based on the prevalence of BV (46%) and VT (12%) (3), the posttest probabilities for the absence of odor and yellow discharge are 6.0% (BV) and 2% (VT). Neither probability is likely to be above one's treatment threshold. Only if miconazole therapy has failed and the patient has persistent or recurrent external genital symptoms would laboratory examinations be performed.

David A. Nardone, MD
Professor EmeritusOregon Health & Science University
Portland, Oregon, USA

In response

Dr. Nardone is correct about the negative predictive value of the symptom of lack of odor for BV. He is also correct that lack of yellow discharge makes VT less likely, but this is only when seen on physical examination, and this conclusion is based on only 1 study of 9 patients. Further, it is not clear that lack of yellow discharge as a symptom is valuable for diagnosis of VT.

We felt that lack of itching was reasonably diagnostic in eliminating candidiasis. Thus, our formulation was that while symptoms were generally not good in distinguishing among the 3 causes, lack of itching makes Candida less likely and lack of odor makes BV less likely.

Matt Anderson, MD, MSc
Albert Einstein College of Medicine
Bronx, New York, USA


References

1. Doust J.Review: Vaginal signs and symptoms perform poorly in diagnosing vaginal candidiasis, bacterial vaginosis, and vaginal trichomoniasis. ACP Journal Club. 2004 Sep-Oct;141:47. [PubMed ID: 15341467]

2. Nardone DA, Roth KM, Mazur DJ, McAfee JH. Usefulness of physical examination in detecting the presence or absence of anemia. Arch Intern Med. 1990;150:201-4. [PubMed ID: 2297289]

3. Landers DV, Wiesenfeld HC, Heine RP, Krohn MA, Hillier SL. Predictive value of the clinical diagnosis of lower genital tract infection in women. Am J Obstet Gynecol. 2004;190:1004-10. [PubMed ID: 15118630]